One skill I’m developing in my practice is Intradialytic Parenteral Nutrition (IDPN). So if you, like me, want to learn more about IDPN, this post is a practical introduction and will likely be the first of several on this topic.
What Is IDPN?
IDPN is a form of parenteral nutrition delivered during a hemodialysis (HD) session. As many people come for HD three times per week, typically IDPN is also provided three times per week. The authors of today’s reference recommend a duration of 4–6 months to achieve meaningful nutritional benefit.
Why Use IDPN?
Adults with end-stage renal disease (ESRD) on hemodialysis are at high risk of protein-energy wasting (PEW). Nutrition interventions to prevent or manage PEW may include:
- Nutrition counseling
- Oral nutrition supplements (ONS)
- Intra-dialytic parenteral nutrition (IDPN)
The 2020 KDOQI Nutrition Guidelines in CKD emphasize that IDPN can help improve and maintain nutritional status when oral or enteral intake is insufficient:
“4.1.3 Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN) Protein-Energy Supplementation: In adults with CKD with protein-energy wasting, we suggest a trial of TPN for CKD 1–5 patients (2C) and IDPN for CKD 5D on MHD patients (2C), to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake.”
Despite this recommendation, surveys in Australia and elsewhere indicate that lack of knowledge about IDPN is a key barrier to its use.
Indications for IDPN
IDPN should be considered for patients who:
- Are malnourished or at risk of malnutrition
- Are receiving hemodialysis
- Can be safely fed orally but cannot meet nutritional requirements through diet, counseling, or ONS
- Are non-critically ill hospitalized patients with acute kidney injury (AKI) or on HD
Contraindications
IDPN is supplemental; ideally patients should be meeting at least 50% of protein and energy needs through oral intake. Other thresholds for oral intake prior to starting IDPN are:
- Protein ≥ 0.8 g/kg/day
- Energy ≥ 20 kcal/kg/day
Other contraindications to IDPN are:
- Baseline triglycerides > 500 mg/dL (5.65 mmol/L)
- Evidence of volume overload
- Uncontrolled diabetes or hypertension
- Critically ill or acutely ill patients (for whom total parenteral nutrition is recommended)
Nutrients Provided by IDPN
IDPN provides a combination of:
- Protein (amino acids)
- Carbohydrates (glucose)
- Lipids (fat)
There is no standardized IDPN composition. Older guidelines suggested:
- 30–60 g protein per session
- 800–1200 kcal per session
- 30–175 g carbohydrate (DGEM 2015: max 50–80 g)
- 20–50 g fat (DGEM 2015: max 20–30 g)
2020 KDOQI and 2021 ESPEN guidelines do not recommend fixed amounts, but the authors provide guidance:
- Protein: 0.6 g amino acids per kg body weight per session
- Glucose: ≤ 4 mg/kg/min
- Volume: < 300 mL/hour (to avoid hypertriglyceridemia, hyperglycemia, or hypoglycemia)
Micronutrients are generally not included in commercial IDPN bags, but can be added for patients with known deficiencies.
How to Administer IDPN
Considerations for safe administration:
- Ensure dialysis staff are trained and feel competent and confident
- Set pump flow rates according to formulation and patient safety
- Start infusion 15 minutes after HD begins once pressures and vital signs are stable
- Include IDPN volume in ultrafiltration calculations to prevent fluid overload
Titration schedule:
- Week 1: 50% of target infusion rate
- Week 2: Progress to full infusion rate
Monitoring for Adverse Events
Signs of potential complications:
- Nausea, vomiting, malaise
- Arterial hypotension
- Respiratory distress
- Cardiac arrhythmias (rare)
- Electrolyte disturbances (especially first sessions)
- Hyperglycemia or hypoglycemia
- Hyperlipidemia
- Volume overload
Blood glucose monitoring:
- Diabetic patients: before HD, mid-session, and at the end of every IDPN session
- Non-diabetic patients: same schedule for first three sessions, then only as needed
Triglycerides monitoring:
- Baseline: 1 week before starting
- Weeks 1–2: weekly
- After stabilization: every 4–6 weeks
- Pause IDPN if TG > 900 mg/dL (10 mmol/L)
Other labs: CBC, electrolytes, urea, creatinine, liver function weekly for first two weeks, then every 4–6 weeks.
How to Assess Effectiveness
Use the same components of a standard nutrition assessment, including:
- Biochemical markers (albumin, prealbumin)
- Anthropometry
- Subjective Global Assessment (SGA)
- Handgrip strength
When to Discontinue IDPN
Three main criteria:
- Improvement in nutritional status (≥3 of the following):
- Albumin ≥ 3.8 g/dL for 3 months
- Increase in dry weight
- SGA improvement
- Caloric intake ≥ 25–30 kcal/kg/day
- Protein intake ≥ 1 g/kg/day
- Complication or intolerance to IDPN
- No improvement after 4–6 months, or total parenteral nutrition is indicated
Outcomes Supported by the Literature
- Improved nutritional status when combined with dietary counseling
- Reduced inflammation in patients with protein-energy wasting
- Limited evidence for quality of life or survival, though retrospective studies suggest higher survival rates among patients receiving IDPN compared to matched controls
✅ Key Takeaways for Dietitians
- IDPN is a supplemental nutrition strategy for malnourished or at-risk HD patients
- Safe administration requires trained staff, careful monitoring, and incremental titration
- Clinical effectiveness should be monitored with standard nutrition assessments
- Evidence supports improved nutritional status and reduced inflammation, but survival and quality of life data are limited
Introduction to IDPN for dietitians working in HD
Heading to my RD only section to download a copy.
